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					   Medication Management and
 Medication Errors in Assisted Living

 Heather M. Young, PhD, GNP, FAAN
 Oregon Health & Science University

    Margaret Murphy Carley, JD, RN
retired Oregon Health Care Association
Funding Sources:
WA and OR: National Institute of Nursing Research
NJ: Robert Wood Johnson Foundation, Assistant Secretary
for Planning and Evaluation, DHHS
IL: Sarah S. Fuller Memorial Scholarship, NIU School of
Nursing Illinois Department of Healthcare and Family
Services, Medicaid Advisory Committee, Long-Term Care
Subcommittee
      Focus of this symposium
   Present findings from two studies of
    medication safety in Assisted Living
   Overview of policy variation across 4 states
   Variations among medication aide and
    RN/LPN roles in assisted living
   Medication errors and strategies to prevent
    errors
   Conclusions
      Medication Study Investigators
Heather Young, PhD, GNP, FAAN, Principal Investigator,
  Oregon Health & Science University
Suzanne Sikma, PhD, RN, Co-Principal Investigator,
  University of Washington Bothell
Susan Reinhard, PhD, RN, FAAN Co-Principal Investigator,
  Rutger’s University Center for State Health Policy
Donna Munroe, PhD, RN, Co-Principal Investigator,
  Northern Illinois University
Juliana Cartwright, PhD, RN, Co-Investigator, OHSU
Wayne McCormick, MD, MPH, FACP, Co-Investigator, UW
Shelly Gray, PharmD, Co-Investigator, UW
     Medication Study Team
Gail Maurer, PhD, Project Director
Tiffany Allen, BS, Data Manager
Carol Christlieb, MN, RN, Research Associate
Linda Johnson Trippett, MSN, RN, Research Associate
Elizabeth Madison, PhC, RN, Research Assistant
Sandra Howell-White, PhD, Research Associate
Janis Miller, RN, BSN, Research Assistant
Kathy Veenendaal, MS, APRN-BC, Research Assistant
Kari Hickey, BS, RN, Research Assistant
Lyzz Caley, BS, RN, Research Assistant
Lynette Jones, PhD, RN, Consultant
Study 1: Medication
Management in Assisted Living
        Design and Methods
   Descriptive, multiple methods
       Medication Administration Observations
        (n=4802 medications)
       Focused interviews with RNs, med aides,
        administrators, physicians and nurse
        practitioners, pharmacists (n=113)
       Resident record review (n=187)
The settings

Fifteen assisted living settings
  in Washington, Oregon, New
  Jersey & Illinois
 4 in OR, WA & NJ; 3 in IL
     State assisted living variations:
     Oregon and Washington

         Oregon                 Washington
Most are for-profit      3 profit/1 non-profit
All part of a chain      Chain/stand-alone
Higher Medicaid, some    Favor private pay, some
 private pay              Medicaid
Focus on frail older     Lighter level of care
 adults, retain longer
       State assisted living variation:
       New Jersey and Illinois
     New Jersey                      Illinois
Chain/stand-alone      Chain/stand-alone
Favor private pay,     Two Programs:
 some Medicaid          Assisted Living (AL; private

Focus on frail older    pay, lighter level of care)
 adults                 Supportive Living

                       Facilities (SLF; Medicaid
                        waiver, nursing home
                        alternative)
     Nursing Delegation
   Training and assigning tasks related to
    nursing care and/or medication
    administration
   Some states allow medication administration
    without delegation, variations in amounts of
    nursing oversight
   May be governed by state nurse practice act
    and administrative rules
   Impacted by state licensing statutes and rules
    for community based facilities
    Nursing Delegation

   Legal liability
   In some states, there is an statutory
    immunity for the actions of the
    unlicensed persons for nurses who
    delegate
       State policy variation:
       Oregon and Washington
          Oregon                          Washington
>25 yrs delegation               >10 yrs delegation
Specific delegation for          Specific delegation (not
  injections and finger sticks     insulin) + supervise self-
                                   admin of meds
No certification                 Registered NA (28 hr
Teaching to a group for            fundamentals)
  most medications            Delegation training (9 hrs)
On the job training at         BON approved course with
  discretion of RN, guided by  RN follow-up in facility
  statute
        State policy variation:
        New Jersey and Illinois
         New Jersey                           Illinois
>10 yrs delegation                Medication administration by
Specific delegation                 a licensed health care
  including pre-filled insulin;     professional (AL)
  no self-med supervision         Medication set-up, follow-up
Certified med aide                  and administration by
(3 days) BON approved               licensed nurse (SLF)
  course with written             No Med Aides in AL or SLF
  competency exam                 Policy note * Med Aides allowed in Community
Delegation training in                Independent Living Facilities (CILA) for
                                      Developmentally Disabled and Mentally Ill
  facility by RN
        Medication Study-Facility
        Characteristics
                        OR     WA     NJ     IL      Overall
                                                     Average
Licensed Capacity (#)   95     73.8   110    108.3   95.9
Actual Occupancy (#)    80.7   60     94.5   85.3    79.8
Occupancy (%)           84.9   81.8   85.9   81.2    83.6
% Private Pay           52.7   65     82.5   29      67.6
% Medicaid              47.3   35     11     13      30.9
# admissions/year       20     25.3   48.5   13      27.7

Annual Resident         21.6   36     43.7   11.7    29.4
turnover (%)

Annual Staff            57.0   88.0   28.6   15.9    49.7
Turnover (%)
   Resident characteristics (n=187)

80% female
Average age = 81.8, range 50-103
73.1% private pay
Average length of stay = 1.7 years
59.7% alert/oriented
Variations in number of diagnoses and
need for ADL assistance
                              ADL Need & # Major Diagnoses

              7
                                                        # ADLs
                          6              5.9            # Major Diagnoses
              6                                                               5.7

              5
Ave. Number




              4                                                   3.6

              3

              2   1.73             1.6                                  1.6
                                                       1.2
              1

              0
                     OR              WA                      IL             Ave
                                               State
    Medication use

77.5% of residents needed assistance with
 medications
Residents were taking an average of:
 10 routine medications
  3 PRN medications
 13 total medications
                                    # of Medications per resident
                                                                                                PRN
                                                                                                Routine
         18.0
                             16.5                                                               Total

         16.0

         14.0                                    13.1                                                             13.0
                                                                                         12.4
         12.0                                                                     10.9
                      10.4                10.0                        9.9                                 10.0
Number




         10.0
                                                               8.5
          8.0
                6.1
          6.0

          4.0                       3.1                                                            3.0

          2.0                                           1.4                 1.5


          0.0
                      OR                  WA                   NJ                  IL                     Total

                                                              State
Med Aide Photos
       Pharmacy Service to AL
   Corporate assisted livings used corporate
    pharmacies primarily, local pharmacies for back-
    up
   Stand-alone assisted livings used local pharmacy
   Most facilities in OR and WA used bingo cards,
    one used cassettes, NJ and IL favored multi-
    drug packs
   OR used med trays, WA and NJ used med carts,
    in IL medications were in each resident room
Med Packaging
Pre-pouring Meds
Med Carts
      Med Admin Process
   Identifying residents varied (cups with room #
    or name or picture, MAR with picture, verbal ID)
   OR: Mass pre-pouring into trays
   WA: Individual pouring from carts
   NJ: Some pre-pouring, some individual
   IL: Individual delivery in resident room
   Documentation varied – some when pill was
    popped, others after pill was given
   Privacy was in issue for 11 facilities
    Pre-Pour

   In April 2007, Oregon proposed a new
    rule for ALFs related to the accepted
    methods of delivery which include pre
    pour
   Document after the medications are
    given
    Medication aides
                                Med Aide Employment

          60.0%




          50.0%




          40.0%
Percent




          30.0%




          20.0%




          10.0%




          0.0%
                  0-6 months   7-12 months   13-18 months   19-24 months   25 months and up
                                         Employment Length
                                       Med Aide Education by Degree




          60.0%
Percent




          40.0%




          20.0%




          0.0%
                  Middle School HS Freshman HS Sophmore   HS Junior   High School Some College   AA Degree   3 years   Bachelors
                                                                      Degree/GED                             College    Degree

                                                             Education Level
    Med Aide Training
    (self-reported)


On the Job (%)    53

In-Service (%)    5
Course (%)        20

CNA (%)           30 (WA, NJ, IL)
        Focused Interviews
Data were analyzed using constant comparative
  analysis
 This analysis focuses on
       Perceptions of the role of Unlicensed Assistive Personnel
        ―UAP’s‖ involved in med administration
       Perceptions of training needs for UAP’s involved in med
        administration
       Perceptions of the role of RNs in assisted living
       Conclusions and implications for UAP and RN roles
   The following slides reflect composite perceptions
    from the perspectives of UAP, RNs, administrators,
    pharmacists, physicians, and residents
       Perceptions of the UAP Role in
       Medication Administration

   Medication administration tasks, including those
    delegated, many time constrained
   Medication stocking, delivering tasks
   Communicating
   Problem solving
   Team participation & leadership
   Systematic quality monitoring
   Multi-tasking in sometimes chaotic environment
      Training Topic Ideas for UAPs
   Med info/drug updates/purpose of meds
   Common diseases: delirium, depression, dementia,
    diabetes, osteoporosis
   How to pass medications-5 R’s, system
   How to give meds properly
   Side effects of meds
   Pain management/hospice
   Special meds-diuretics, psychotropics, pain meds,
    coumadin-blood levels, new drug interactions
   When to call the MD/NP
   How to treat residents respectfully
   Medical terminology
     Medication Aide Training

   Check state rules for training
    requirements
   Some state specify content, credentials
    for instructors and required hours
       UAP Role: Implications
   In all settings, UAPs were responsible for giving meds to
    residents & they generally do remarkably well given their
    varying levels of training and preparation
   Medication aide role is central to safe medication
    management in AL settings
   Careful definition of scope of practice/service (Individual &
    Facility)
   Rewards & recognition
   Systematic organizational support
   Training opportunities
   Note: Not all medication aides are UAP, some are certified
    as medication aides under state rules
       Perceptions of the RN Role* in
       Assisted Living
   Delegation and teaching
   Clinical oversight of medication delivery
   Clinical oversight of resident health & care
   Coordination of admission, discharge and
    ongoing service plans
   Administrative/system role
   Coordination with physicians and NPs,
    residents & families
   *Selected RN role functions were being done by LPNs in
    some settings studied
    Perceptions of the RN Role in
    Assisted Living
   Medication Error review and action
   Consultation to UAPs
   Teaching
   Quality monitoring and supervision of med aid
    performance and med admin accuracy
   Accountability
   Records
   Drug regimen review, assess for self
    administration abilities
       RN Role: Implications
   RN role is complex-linking multiple intersecting
    parties and systems
   Strong leadership, supervision & monitoring
    components to role
   Role priorities are heavily influenced by state
    regulations
   Role emphasis predominantly on task oriented
    (e.g. delegation) or reactive situations (a
    problem) rather than a proactive role in which
    monitoring and management of high-risk
    situations and community health promotion is
    central.
       RN Role: Crucial, yet unevenly
       enacted across states
   Consistent role of overseeing med management
    program and monitoring resident health (all 4 states)
   Inconsistent comprehensive review of total resident
    medication regimens with attention to med reduction
    by facility nurses, PCPs & pharmacists (NJ and select
    WA facilities strongest)
   Med administration-day to day-IL RNs most involved
   NJ-RN role most consistently evolved RN role with
    higher staffing requirements, expectation to monitor
    high-risk residents and focus on medication reduction
        Nurse Delegation
   OR-RN role most limited and focused on
    delegation (mostly of insulin and blood
    glucose testing)
       Note: Oregon is revising ALF rules with changes in
        the role of the nurse
       Rules allow the administration of medications in
        the ALFs, but require nursing delegation for tasks
        of nursing
       Delegation rules used to distinguish between
        assignment and delegation, revised to allow
        teaching for non injectable medications
   RN role is bounded by both regulatory and
    fiscal parameters
      Nurse Delegation
   WA – One aspect of RN role, delegation of
    oral and topical medications, blood
    glucose testing
   NJ – One aspect of RN role, delegation of
    oral medications, insulin, blood glucose
    testing
   IL-no delegation
Medication Administration
Observations
   29 medication aides
   56 medication passes
   510 residents
   4802 medications

Observations followed by record review
             Medication errors
             (with and without time)
                                                                                                                                    % error
           45.0%
                                                                                            41.0%     41.3%                         % error without time

                                                  38.5%
           40.0%
                                                                                                                 34.1%
           35.0%
                                                                       29.9%                                                30.1%
                                                                                                                                       29.3%       29.2%
                                                             28.5%
           30.0%              28.0%
% errors




           25.0%
                                                                                  21.4%

           20.0%
                                        16.1%                                                                                             16.0%
                   13.6%
           15.0%                11.9%
                                                                                                        13.1%

                      9.9%                10.5%
                                                                                     9.1%
           10.0%                                                                                                                                      8.3%
                                                     6.9%                                     6.7%
                                                                                                                    5.6%
                                                                                                                               4.8%
            5.0%                                               3.0%       2.3%


            0.0%
                     OR - A    OR - B    OR - C     OR - D    WA - A     WA - B    WA - C    WA - D     NJ - A     NJ - B     NJ - C      NJ - D    Overall
   Types of errors

                   Extra dose   Wrong drug
    Unauthorized                  0.2%
                     3.7%
       drug                                  Wrong dose
       1.4%                                    11.3%


Omitted dose
  12.2%




                                               Wrong time
                                                 71.3%
     Clinical significance of errors
   1402 errors were analyzed for clinical significance
    by geriatrician, GNP, and geriatric pharmacist
   Two ratings: likelihood of causing harm and
    severity of potential harm
   No errors were judged to be highly likely to
    cause severe harm
   3 errors were judged to potentially cause
    symptoms
   Lower error rates than hospitals (average 19%)
    Summary of errors rated < 8
    (score below 6 is clinically significant)

       Ordered                     Given           Likelihood of harm +
                                                      Severity Score
No order                  Diazepam 10 mg                   4.0*
No order                  Novolin 26 units                 4.0*
Humalog 10 units          Humalog 18 units                 6.0*
Humulin 70/30 42 units    Humulin 70/30 68 units           6.3
Lasix 80 mg qd            Lasix 80 mg bid                  7.0
Lasix 80 mg qd            Lasix 80 mg bid                  7.0
Glipizide ER 10 mg qd     Glipizide ER 10 mg bid           6.6
Coumadin 4 mg             Coumadin 8 mg                    7.0
Lasix 80 mg qd            Lasix 80 mg bid                  7.0
Humalog 25 units            Humalog 32 units               7.7
   * Potentially clinically significant
    Error rates for high risk drugs

Drug        Total        Total errors
            observations
Insulin     24           7

Coumadin    48           2


Lasix       89           28
        Strategies to limit errors
                                                           Consequences
Causes of errors                         Types of errors       to staff
•Communication                             •Omission         Discipline
     •Ordering                              •Wrong           Oversight
    •Dispensing                              Person           Training
   •Resident ID                               Drug
 •Admin Process                               Dose         Consequences
   •Staff factors                            Timing          to resident
                     Strategies to                          Quality of life
                       limit errors                        Adverse events
                    •RN involvement                         ER/hospital
                      •8-7-5 rights
                      •MAR audits                          Consequences
                     •Observations                            to facility
                           P&P                                 Liability
                    •Limit distraction                       Reputation
                      •Supervision                            Citations
                         •Training
      Overall Impressions
   High volume of meds – high demands on
    med aides
   Compressed time frame for medication
    administration- adjust timing?
   Bulk of meds are low risk, routine – need to
    focus on high risk meds/residents
   Very few errors pose potential for harm
   Med aides generally do remarkably well
    with level of training and preparation
       Overall Impressions

   Residents are assessed more with change of
    condition – not proactively or by risk
   Lack of comprehensive review of total
    medication regimen – med reduction
   Minimal trending/big picture/system issues
   RN role is crucial, and unevenly enacted
       Overall Impressions
   MD/NP on-site involvement makes a
    difference in appropriateness of meds,
    resident assessment, problem solving, overall
    health management
   Reimbursement is an issue for Primary Care
    Practitioners and pharmacy
   Many systems for medication management
    exist – there is not a single answer, more
    important is how well the system is used
        Strategies: Priority Areas
   Limit distraction – FOCUS
   Optimal communication
   Review medications/MAR/systems
   Consistent and clear orders including DC
    orders
   Unambiguous packaging
   Verify resident identification
   Have good policies and procedures and train
   Monitoring and supervision
    Strategies: Priority Areas
   Prioritize RN involvement to areas of highest
    impact, e.g., with high risk residents and
    high risk meds
   Develop and implement safeguards for high
    risk medications (e.g., coumadin, insulin)
   Systematic drug regimen review (appropriate
    prescribing and communication among
    multiple prescribers)
   Medication reconciliation particularly with
    transitions
   Optimal use of technology to promote safety
    (e.g., ePrescribing, client ID, bar coding)
        Implications

   Acuity of AL residents increasing and so is
    the complexity of medication management
   Medications management is both a person
    and a system issue
   Timing is a major issue – relevance of 2
    hour window for a med to be untimely?
   RNs play a vital role in resident assessment,
    and training, supervision of med aides
Study 2:
Using Results of the Oregon Long-
Term Care Medication Safety Study
to Reduce Medication Errors




             Used with permission of Sharon
                   ConrowComden, Dr.PH, Outcome
                          Engineering
                              and
                      Oregon Health Care Association
                      Research funded by AHRQ Grant # UC1HSO14259
      Baseline Denominator Data from
      Random Sample of MARs:
   NF                                   CBC
     8.33 mean active                      7.52 mean active

      orders per                             orders per
      resident/mo                            resident/mo
                                            35 MAR changes
     53 MAR changes per
                                             per resident year
      resident year
                                            3022 doses per
     2898 doses per                         resident year
      resident year
    * Drugs exclude OTC drugs, patches, IVs, drops, inhalers, etc
      Medication Management Process
      Flow as Modeled in this study

                                   Medication
Ordering        Transcription                   Administration
                                   Processing

     Wrong Drug
       36 failure combinations

       Approximately 840 basic events

     Wrong Dose
       34 failure combinations

       Approximately 940 basic events

     Wrong Resident
       32 failure combinations

       Approximately 920 basic events

     Omission
        58 failure combinations

        Approximately 920 basic events
  Estimated Errors Reaching
  Resident Per Year

                   Errors Per       Errors Per CBC
Type             Nursing Facility   Resident Year
                 Resident Year

Wrong Drug             5.9               7.0

Wrong Dose             2.8               2.8

Wrong Resident         1.0               0.7

Omission               70                70
   Using the Risk
   Models-- Example: Wrong Resident

Definition:

One or more drugs delivered to the wrong
 resident—includes prescriber, pharmacy,
 nurse, and medication staff errors.
      Wrong Resident—Highest Risks


   Drugs given to the wrong mobile/familiar
    resident--slip
   Drugs given to the wrong mobile/unfamiliar
    resident
   Resident incorrectly identified--Slip
   Resident given wrong drug due to wrong
    resident written on telephone order
Single Failure Paths
   Prescriber misidentifies resident in
    initial order
   Attempting administration with
    incorrect familiar resident
   Nurse or aide writes wrong name
    on cup of meds set aside when
    resident is unavailable
       Active Controls—intended to
       detect and correct the error

   Resident photo in MAR
   Name alert policy if two or more residents with
    similar names in facility
   Closed compartment med trays (if pre-pour)
   Order sheets include resident’s name, DOB,
    height, and weight
   Store med cards by resident name, one
    card/drug, pull by MAR
    Passive Controls—not intended to
    catch specific error but may detect it

   Resident familiarity with own drugs
   Dual failure path between MAR and
    pharmacy filling from original prescriber
    order
   Nurse review of order
   Pharmacy review of order
    At-Risk Behaviors

   Resident name not being read back
    during telephone order—occurs 95% in
    NFs and CBCs
   Name on bubble pack not checked
    against MAR; estimated that 33% of
    nursing and 38% CBC do not compare
    all or part of the ―five rights‖ on the
    label to the MAR.
    Top Risks for Wrong
    Resident

   Walk up to wrong mobile, familiar
    resident and give them someone else’s
    meds—a lapse error or memory failure
   Resident isn’t available, store cup
    w/drugs, pick up wrong cup and give
    them someone else’s drugs—a slip error
     Wrong Drug

Definition:
Wrong drug—resident receives a drug that
 is not clinically indicated or a drug
 administered that was not ordered for this
 resident—including a discontinued drug
 (d/c’d) that continues to be administered.
Wrong drug‖ errors includes errors by physician, pharmacy, nurse, and
―

  med aide. Model does not include over-the-counter drugs, vitamins,
  ointments, eye drops, patches, IV, or inhalers.
       Wrong Drug—Highest Risks

 No D/C order—40-60% of drug change or drug
  dose orders. Wrong Drug Error Risk=3.93/1000
  orders
 D/C not received (illegible handwriting, fax isn’t
  sent or doesn’t go through) Risk=1.66/1000
  orders
 Transcription errors (failure to transcribe or
  delaying d/c order onto MAR, wrong drug d/c’d,
  no second check on transcription before first
  dose given (Survey: only 17% NFs and 69%
 CBCs check transcription before dose given)
 Duringtelephone order, nurse transcribes wrong
 drug onto order
      Wrong Drug: Single Failure Paths

   Prescriber orders wrong drug
   Prescriber fails to write DC order
   DC transmission error
   Resident does not return DC order
   Staff loses DC order
   Staff pulls wrong drug card, e.g.,
    oxycontin for oxycodone
      Wrong Drug At-Risk Behaviors

   NF’s: Choosing not to transfer D.C. order to MAR
    Cards not checked against MAR before
    administration (38%)
   CBC’s: Choosing not to transfer D.C. order to MAR
    Cards not checked against MAR before
    administration (33%)
   Both: Not pulling D/C’d cards promptly
Wrong Dose

Definition:
Resident is prescribed a dose or frequency
  other than what is clinically indicated or
  receives a dose or frequency other than what
  was prescribed. If a single dose is missed in
  a med pass, it is included in the omission
  model.

―Wrong dose‖ errors includes errors by prescribers, pharmacy,
  nurses, and med aides. Model does not include over-the-
  counter drugs, vitamins, ointments, eye drops, patches, IV, or
  inhalers.
      Wrong Dose: Highest Risks

   Resident receives wrong dose due to
    prescriber new, temporary, or change order
    error
   Non-obvious bubble pack error like the
    wrong pill that is not obvious by color or
    shape
     Wrong Dose: Single Failure Paths

   Nurse or aide pulls wrong card when there
    is more than one dose and doesn’t check
    against MAR
   Nurse or aide draws up wrong dose of
    insulin and administers it
   Nurse or aide miscalculates dose and no
    check in place to catch it
       Examples of Active Controls

   Bubble packing of drugs; 85% of oral solids (pills,
    capsules, etc.)
   Second check on order transcription (60% of NFs and
    90% of CBCs do check but only 17% of NFs and 69% of
    CBCs before first dose)
   Read back dose (about 90% of NFs and CBCs report
    doing this routinely)
   Dose checked against the MAR (38% NFs and 23% CBCs
    report not checking at every med pass)
   Calculation proficiency checks--rare
   Pharmacy checks (within limits only)
Active control examples
   Flags, stickers, logs for new, DC, and change orders
   Prefilled syringes
   Sliding scales—if include mixes of short and long
    acting insulin, can increase risk of wrong
    strength/form errors
   Double checks on injectables (Survey results: 40% of
    NFs and 30% of CBCs report doing this)
   Transmit request for orders with resident age, height
    and weight; copy of MAR; and recent labs—aids
    pharmacy
   Require Fax to Confirm All Orders within 24 hrs
    (Survey: 10% do this)
      Wrong Dose At-Risk Behaviors

   Read back does not occur (50% NFs and
    100% of CBCs require read backs of TOs but
    15% failure rate estimated)
   MAR not checked against dose on card; 48%
    failure rate estimated.
   Borrowing drugs without investigating order
    thoroughly
   Card not pulled after D/C order processed
    Wrong Dose: Top Six from NC NHs

                                  Tranquilizer/
1    Ativan (Lorazepam)           Anti-convulsant
2    Warfarin (Coumadin)          Anti-coagulant

3    Insulin (all types)          Anti-diabetic

4    Hydrocodone combinations Narcotic

5    Lasix (furosemide)           Diuretic

7    Duragesic (fentanyl patch)   Narcotic
Omissions
Definition:

Resident did not receive ordered drug
 including refusals


Omission errors includes errors by prescribers, pharmacy, nurses, and med
  aides. Model does not include over-the-counter drugs, vitamins,
  ointments, eye drops, patches, IV, or inhalers.
         Omission—Highest Risks

   Delays due to preauthorized drug process-- up
    to 10 days, average of 4.3 for NFs and CBCs
   Resident not available for med pass—5-6% from
    validation survey
   Offsite prescriber order errors
       Prescriber forgets to order drug
       Order faxed to pharmacy and facility does not get
        order prior to first dose
       Resident does not return order
       Prescriber order transmission error
         Omission: Single Failure Paths
                                       Telephone order not
   Prescriber forgets to write         recorded
    order                              Drug not dispensed by
   Staff misplaces written order       pharmacy
   Resident forgets to return         Drug mislabeled by
    order from off-site exam            pharmacy
   Fax transmission error             Drug lost in transmission
   Preauthorized drug ordered          from pharmacy
   Pull wrong sticker on reorder      Resident refuses drug
   Forget to reorder                  Med aide / nurse forget to
   Handwritten order written           give drug
    incorrectly                        Resident unable to swallow
   Refill order not transmitted       Resident not available during
                                        med pass
      Medication delivery systems-what
      the risk models tell us

   Some processes are robust—3, 4, or 5 errors
    required for undesirable outcome
   Some are thin, only one error required
   Unfamiliarity drives extra steps, e.g. verifying new
    resident identity with other staff
   Safety is maintained through defense-in-depth
    strategy, except for initial physician ordering and
    final delivery of medication to patient
        What We See in the Risk Model

   The Impact of Single Failure Paths
       eg. prescriber orders wrong drug

   The Impact of At-Risk Behaviors
      eg. choosing not to check card against MAR


   The Impact of Active Controls
       Example is order read back
   The Impact of Passive Controls
       eg. pill shape and color
       Three Practical Applications for
       Your Settings
   Two independent IDs to reduce wrong
    patient/resident med errors — if implemented by
    only 30% of NFs and CBCs in Oregon, could
    prevent 300 potentially serious errors every year
   Improving order, fax, and TO forms to reduce
    wrong drug/dose errors—if implemented in only
    30% of Oregon NFs and CBCs; prevent 17,800
    errors/yr
   Reducing wrong drug/dose/strength insulin
    errors—some of most serious med errors in OR.
     Assignments: How would you
     do the following?

   Two independent IDs to reduce wrong
    patient/resident med errors
   Improving order, fax, and TO forms to
    reduce wrong drug/dose errors
   Reducing wrong drug/dose/strength
    insulin errors
      Conclusions
   Medication errors can be reduced
   More commonly errors are a system problem
   Error reduction requires a safety culture
    mentality (no shame and blame)
   Policy makers should address the need for
    requisite resources (i.e., UAP) and
    professional services in managing
    medications for chronically ill frail older adults
    in these settings

				
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